Nursing practices and attitudes towards mean arterial pressure management in critically ill patients receiving vasopressors: A multicentre survey study

BACKGROUND: Observational data demonstrate a gap between prescribed and achieved mean arterial pressure (MAP) targets in critically ill patients receiving vasopressor therapy, with delivered MAP values consistently 7-10 mmHg higher than prescribed targets. The mechanisms underlying this discrepancy remain poorly understood, particularly the role of bedside nursing practices. OBJECTIVES: The aim of this study was to evaluate bedside nursing practices, attitudes, and perceived barriers related to vasopressor management and MAP targeting and to identify nursing-related factors contributing to the observed gap between prescribed and achieved MAP values. METHODS: A multicentre, cross-sectional mixed-method survey study was conducted at three tertiary intensive care units (ICUs) in Australia and New Zealand between May and August 2025. The electronic survey examined alarm-setting practices, clinical decision-making factors, tolerance for subtarget MAP values, and attitudes towards MAP management strategies. Eligible participants were ICU nurses with direct patient care responsibilities. RESULTS: A total of 278 ICU nurses responded across three sites. Most nurses (72.0%) frequently cared for patients receiving vasopressors on ≥50% of shifts. For MAP targets of 60, 65, and 70 mmHg, nurses set lower alarm limits at medians of 59, 63, and 68 mmHg, respectively, while upper alarm limits were set 15-20 mmHg above prescribed targets. Nurses demonstrated limited tolerance for subtarget MAP values, accepting deviations for median durations of only 3-5 min. Patient instability was the most frequently cited factor influencing titration decisions (86.0%). While 57.9% of nurses were comfortable with achieving a higher MAP than prescribed, 89.6% were comfortable decreasing vasopressor doses to correct this situation. Strong support existed for educational interventions (91.4%) and standardised protocols (71.7%). Thematic analysis identified four barrier themes: patient responses, clinical uncertainty, multidisciplinary influences, and factors impacting practice. CONCLUSIONS: Liberal upper alarm limits set 15-20 mmHg above prescribed MAP targets, combined with brief tolerance for subtarget values, create asymmetric management practices that systematically enable upward MAP drift and explain the persistent gap between prescribed and achieved targets.